Elder. National education program lifts the veil on misinformed perspectives about what constitutes abuse.

Transcription

1 12 September/October 2011

2 Elder Abuse RNs recognize/respond to/report National education program lifts the veil on misinformed perspectives about what constitutes abuse. by Lesley Young Does failing to ask what a resident at a long-term care home would like on his toast constitute elder abuse? The answer: yes. If you re surprised, you re probably not as savvy on the issue as you should be. But you re not alone. This scenario, based on a real incident, illustrates neglect, one of six categories of abuse, and perhaps the most misunderstood. Here s the thing about elder abuse: until you ve been engaged in meaningful education, you probably don t understand it fully and completely. This startling revelation comes to you direct from at least four nurses who have worked in long-term care for decades. Take RN Pamela Rowe, manager of nursing practice at Hillsdale Estates in Oshawa. She works at one of 10 facilities nationwide that have been sel ected to participate in the CNA/RNAO Prevention of Elder Abuse Centres of Excellence (PEACE) initiative. By getting involved in the ground breaking project, Rowe hoped she would be improving on existing education in elder abuse. She never dreamed she would be helping to lift the veil on so many well-intended but misinformed perspectives around the issue, including her own. It s been incredibly exciting for me, she says of her role as a coordinator, and her goal to increase understanding among nurses and other health-care Registered nurse journal 13

3 Photo: Jeff Kirk professionals about the important front-line role they play in spotting elder abuse, providing resources to victims and their families, and ensuring dignity and respect in the care of older persons. I m learning a lot by witnessing the changing perceptions of our staff going through the PEACE program. Seeing elder abuse through a different lens has made me a better person and a better nurse. Perhaps no one realized the extent to which the PEACE initiative being tested in centres in B.C., Alberta, Saskatchewan, Manitoba, Ontario, New Brunswick and Nova Scotia until March 2012 would be quite so revealing. Rowe recounts one moment in particular that illustrates the incredible impact of the two-year project. She was out for dinner with her husband after the second day of a three-day PEACE presentation to several hundred prospective RNs, RPNs and personal support workers at a local university. Rowe was thrilled that many of the students who saw her presentation were glued to their seats, some moved to tears. She was even more thrilled when one of the restaurant s wait staff came over to her table to tell her she was a nursing student and had seen the presentation. I just wanted to let you know that you ve changed my life, she told Rowe. I will never look at elder abuse quite the same way again. I can put this curriculum into practice during my nursing career. It still gives me goose bumps just thinking about it, the Oshawa RN says. So what is it about the PEACE initiative that has the nursing community talking? Quite simply: front-line elder care providers are being encouraged in positive, action-oriented, personalized and stigma-free training to question their perspectives. While analysis of the pilot is not yet complete, project lead and RNAO Associate Director Heather McConnell says the initiative is clearly enlightening the nursing community. The five-step training (see specifics in sidebar) covers everything from understanding and recognizing elder abuse, to the law, intervention strategies, and the impact a healthy work environment has on a health provider s ability to deliver appropriate care. It touches on some of the trickier areas of abuse, such as what constitutes neglect, and, at the same time, raises awareness of the importance of respecting the dignity of elders. Ultimately, it is impacting how we feel about the work we do, and the quality of care we deliver. This kind of education is critical if we are to get a handle on rising rates of elder abuse among Canada s older population. According to Statistics Canada, the rate of elder abuse increased 14 per cent between 2004 and As many as 7,900 cases were reported, including instances of physical, emotional, sexual and financial abuse as well as neglect and violation of rights (i.e. the assumption that the elderly cannot make their own health-care decisions). Many more cases go unreported because victims are either ashamed or fear retribution from a family member or caregiver. Caring for the elderly on the front lines every day means nurses are in a prime position to identify, report and ultimately stop elder abuse, says CNA President Judith Shamian. Despite this fact, recent news reports suggest a lack of knowledge, especially around neglect, may be hampering their efforts to do so. In just one example, Upper Canada Lodge, a long-term care (LTC) home in Niagara Region, was found by the Ministry of Health and Long-Term Care to have six violations of the Long-Term Care Homes Act, all related to neglect (improper pain management) after 75-year-old Sylvia Bailey died from complications resulting from an untreated broken leg in March of this year. Pamela Rowe is coordinator of the PEACE project at Hillsdale Estates in Oshawa. The hope is that the PEACE initiative, funded by Human Resources and Skills Development Canada, will help to reduce incidents of elder abuse across the country. RNAO plans to continue this important work when the funding ends, including developing a best practice guideline on elder abuse. Here s how four long-term care homes across the country have adapted the PEACE program to their needs Hillsdale Estates, Oshawa For this 300-bed long-term care residence in Oshawa, adapting the curriculum for over 400 staff was a case of making it accessible and engaging. Rowe explains that they didn t want staff to lose interest by covering the same ground that was already covered by mandatory, annual abuse training offered at their residence. To keep things fresh and relevant, they loaded the content with real-life examples to emphasize and hone problem-solving skills. For example, staff was reminded to never take a bruise for granted. We encouraged them to look at every event through a new lens and ask, for example, what the root cause of a bruise may be, says Rowe. 14 September/October 2011

4 and prevent elder abuse, she says. After just three presentations at a local university and college, several more are set to receive the PEACE curriculum this fall. Rowe believes that educating nursing students on the finer points of elder care and issues around abuse has another plus. Not only will students get a chance to put their education to work in student placements (reinforcing the learning in a hands-on way), she is already receiving applications from students who have expressed a desire to work in a residence that is committed to preventing abuse. It s a win-win recruiting scenario. Bow View Manor, Calgary Until PEACE, education focused on elder abuse was pretty basic for the staff at Calgary s Bow View Manor. PEACE coordinators wanted to change that, and to provide a practical and pragmatic perspective to identifying, reporting and preventing elder abuse. Sandi Hirst, Director of the Brenda Strafford Centre for Excellence in Gerontological Nursing, says that in order to do so, they layered in lots of possible scenarios for discussion. Similarly, staff is walked through the process of problem solving a sudden change in resident behaviour. This is really about giving them the skills they need to be sensitive to spotting it. One really powerful approach taken by Hillsdale has been bringing in the region s elder abuse advisor, as well as the Durham Regional Police senior support coordinator to speak to the law around elder abuse. The officer will recount real-life examples of abuse, and discuss the conditions under which abused elders are found in their homes. The presentation also focuses on typical types of financial scams, says Rowe. Not only does this bring to light how elder abuse occurs in the community, it communicates to employees how serious a crime it is, and gives them the confidence they need to report cases they may encounter, she adds. Reaching a younger demographic While adapting the curriculum to her organization s needs, Rowe says she had a light bulb moment. Why not take it to a grassroots level? Specifically, she envisioned reaching out to as many nursing students as possible, and, in the future, possibly even elementary students. The younger you start, the better prepared you will be later on in life to spot Identifying neglect The curriculum around identifying and preventing neglect provoked a lot of discussion from employees in most of the participating PEACE Centres interviewed for this article. While other types of elder abuse are more obvious, some types of neglect surprised some staff. Hirst said going over possible scenarios helped staff at Bow View understand the difference between active and passive neglect. For example: If a resident is left sitting in her own feces for a couple of hours, which should never happen, it may be because someone failed to check on her (active neglect), or because the care provider is too busy to check (passive neglect). The PEACE program allows staff to stop and think about every situation in the context of putting the resident first, says Hirst. Doing so can help them identify what constitutes neglect, especially in situations where abuse may be unintentional, she adds. For example, to tie back to the real example mentioned at the beginning of this article, if you put peanut butter on a resident s toast without asking what he wants, you are not putting him first. It s disrespectful, and disrespecting a resident is a form of neglect, Hirst adds. The program also gives the nursing community the information it needs to address an abusive situation, including how to approach a concern about neglect with a staff or a family member, and when to report incidences of abuse. Reviewing perceptions Hirst recalls walking around the corner one day only to hear a senior nurse call one resident an old fart. In turn, he replied, You are such a bitch. My initial reaction was shock. I absolutely thought this was abuse, says Hirst. However, after talking about this exchange with the nurse and the client privately, she discovered that this was welcome, saucy banter the two had enjoyed for years. The point is to second guess our perceptions of abuse. She adds that education equips staff to think twice about what they witness, and go about validating whether a situation really is elder abuse. Managing diversity When Hirst first arrived to work in longterm care in Canada from Scotland, she learned very quickly that her practice of calling clients dearie, while totally acceptable in the United Kingdom, was disrespectful here. Given this personal Registered nurse journal 15

5 experience, she made sure the curriculum included scenarios and content to address the diverse cultural backgrounds of staff. The whole point is to get staff to reflect on their behaviour; therefore it has to have relevance to them. York Care Centre, Fredericton This large, not-for-profit long-term care residence on the East Coast has a zero tolerance policy for elder abuse. But before being chosen to participate in the PEACE project, it had no formal abuse education for its 300-plus employees. RN Gail MacFarlane, Manager of Learning Services, explains how the organization appointed 12 PEACE champions, one from each of the facility s departments. The champions completed the PEACE program, and were then responsible for informally transferring that knowledge to co-workers. When nurses in a particular department meet formally, for instance, the PEACE champion might talk about a scenario that illustrates learning from the curriculum. For example, the champion may initiate discussion about what colleagues should do if they walk by a resident s room and overhear a family member belittling him or her, says MacFarlane. Actionable examples help promote dignity Like the other Centres of Excellence, York Care found it helpful to incorporate real-life scenarios into the curriculum. One thing that I ve seen happen a lot in the dining room, and I have even been guilty of this, is not communicating with a resident when you are feeding them, MacFarlane says. Instead of providing an engaging meal-time experience by talking to them, staff might talk to a co-worker across a few tables. This is not a malicious example of elder abuse, she adds. We are all human. But PEACE helps raise awareness about maintaining a resident s dignity, ultimately improving the quality of care nurses and nursing aides provide, she adds. Individualized care helps eliminate neglect To deal with confusion around what might constitute neglect, York Care created scenarios and encouraged staff to make decisions based on an individualized, personalized approach to care that takes into account real-life challenges, such as a shortage of time. For example, they created situations for discussion that would give employees the confidence to make the right call in the moment. A resident argues that he would like to stay in bed and have breakfast on a tray instead of getting up. The family has said they want him up every morning, and so does the RN in charge. Sometimes we get into such a routine that we forget this is home for people, says MacFarlane. Recognizing that, and at the same time recognizing you ve got to get eight or nine other individuals out of bed, washed, dressed and ready for breakfast, will help nurses see that the right thing and the realistic thing may be completely different. PEACE helps employees make the right call in the moment. Winnipeg Regional Health Authority Clinical nurse specialist and PEACE coordinator Judy Robertson says the Winnipeg Regional Health Authority (WRHA) spent a lot of time on the section of PEACE training that emphasizes how an unhealthy work environment can contribute to elder abuse. An unhealthy environment can create an unprofessional workplace culture that lends itself to abusive reactions. It can also lead to a Five steps for promoting awareness of elder abuse in long-term care At the core of the RNAO/CNA Prevention of Elder Abuse Centres of Excellence (PEACE) initiative is a training package divided into five key areas (or modules). Organizations are encouraged to adapt the training as they see fit so long as they don t omit any one area. one two three four Understanding elder abuse: Participants learn why elder abuse is an important issue, and review definitions of the types of elder abuse. Recognizing elder abuse: Participants discover how to identify characteristics of the abuser, of the abused, and identify signs and symptoms of different types of abuse. Learning the law: Participants learn why elder abuse is underreported, how elder abuse is against the law, and the reporting process for suspected/observed abuse. Intervention and strategies: Participants develop strategies for intervening and halting an elder abuse situation in the moment, discuss next-step intervention strategies, and learn about resident-centred care and therapeutic relationships as preventive strategies for elder abuse. Healthy work environments: Participants explore the definition of five a healthy work environment, begin to understand the workplace factors that contribute to abuse, make the connection between a healthy work environment and elder abuse, and consider how their environment may be improved. lack of structure that erodes staff confidence to intervene or report situations of elder abuse. Robertson says this focus led to really great discussions about what a healthy work environment is, and how employees are responsible for creating one. Teamwork and encouragement of all staff to participate in decision making toward patient-centred and respectful care improves outcomes for both residents and the staff caring for them. In one discussion, a health-care attendant related the story of a resident who disliked getting up in the morning at the same time as the other residents. The health-care attendant discussed options with all staff for a later wake-up time and a later breakfast, and management and team members worked together to make it happen. The result was a happier resident and the team feeling their suggestions and ideas were valued. Converting the curriculum to e-learning WRHA worked with an outside e-learning company to develop an online learning presentation for employees who might not have a chance to receive the education in person. PEACE facilitator Susan Bernjak, regional educator for the WRHA Personal Care Home Program, points out that part of the effectiveness of the program is the interactive component; however the content can also be formed into an effective e-learning session for weekend and night staff. RN lesley y o u n g is a freelance w r i t e r /e d i t o r in a u r o r a. 16 September/October 2011